Management of Elevated INRs

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004 How Vitamin K affects INR?

Warfarin and lipitor high inr value

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Initially, quizzes mental illness with anger cruelty posted out with journals and GPs are invited to submit their answers for CME credits.

Register or Log in to take part in quizzes. Register to use all the features of this website, including selecting clinical areas of interest, taking part in quizzes and much more. This item is 7 years and 11 months old; some content may no longer be current. Regular measurement of INR levels is an essential component in the management of patients receiving warfarin treatment.

Many factors can influence INR control so management can sometimes be challenging. Practices are encouraged to develop protocols for warfarin management, warfarin and lipitor high inr value, to minimise the risks and maximise the benefits of treatment for patients. Computerised decision support tools can help to achieve improved therapeutic control. International Normalised Ratio INR testing is well established as an integral part of warfarin treatment.

INR has a critical role in maintaining the warfarin response within a therapeutic range, to provide the benefits of anticoagulation, while avoiding the risks of haemorrhage Figure 1. Therapeutic richard bernstein and diabetes of warfarin treatment requires two key elements to be undertaken if it is to be successful: Although regular testing of INR levels is essential for all warfarin and lipitor high inr value taking warfarin to maintain control of the INR, in practice, INR levels show considerable intra-patient variability.

Balancing the risk of anticoagulation treatment adapted from Blann, warfarin and lipitor high inr value, 1. It is important that practices develop a standardised management protocol for all patients treated with warfarin, in order to optimise health outcomes, by achieving tighter control. The method chosen will depend on how clinical records are managed within the practice but there should at least be a standard location within the patient notes for the following information:.

Regular testing of the INR is essential for all people taking warfarin. The risk of bleeding while on warfarin is greatest in patients who have not previously received warfarin, and in the first three months of treatment.

Any patient on warfarin should be aware of the risks and early warning signs of bleeding, and they should be followed closely, during the first three months in particular, to ensure that the INR does not exceed 3. After this time period, the frequency of INR testing can vitamines and asthma reduced. For most people once the INR is stable, the rate of INR testing can be extended to two weekly and then four to six weekly.

In some stable patients the frequency may be tunnison and associates plans reviewer out to eight weeks.

In most situations the INR target is 2. This range is appropriate for the prophylaxis or treatment of venous thromboembolism and reduction of the risk of systemic embolism for people with atrial fibrillation and valvular heart disease. The target INR may vary depending on individual clinical situations, warfarin and lipitor high inr value.

The target INR for mechanical prosthetic valves is dependent on the type of valve replacement used. For unprovoked DVT or PE the duration again is 13 weeks, but for individual patients within their clinical context, the indefinite use of warfarin may be appropriate. Some fluctuations in INR level can be expected, and for minor variations, changes in weekly doses are usually not required. For more significant fluctuations, use of a standard guide is important to reduce the risk of incorrect dosing.

The use of dosing calendars for more complicated dosage sequencing may be of benefit. Changes in warfarin dosage may take several days to affect INR level, therefore it is important that doses are not adjusted more frequently than every four to five days. Changes in the INR level in a usually stable patient may be due to a number of reasons, including: Patients on warfarin are usually advised to consume a reasonably consistent proportion of vitamin K rich foods such as broccoli, spinach and cabbage.

This is probably most relevant in patients who have had markedly reduced food intake because of illness, hospitalisation, travel and fad warfarin and lipitor high inr value. Increased consumption of alcohol particularly binge drinking can affect warfarin control although moderate, regular alcohol consumption has little effect. Many medicines and herbal products can interact with warfarin. An interaction can occur when the interacting agent is started or stopped or when the dose is altered.

Whilst most interactions involve a change in the INR, it is important to recognise that some interactions cause an increase in bleeding without alteration of the INR, e.

Table 1 shows some of the important interactions with warfarin. It is not all-inclusive and practitioners should always check if there is a clinically significant interaction if they are prescribing a medicine for a person taking warfarin. For a complete list of interactions and advice on managing interactions such as when to check the INR, refer to appropriate information resources such as a formulary or your PMS system. Some of the main medicines, medicine classes and other agents that can interact with warfarin adapted from Juurlink, An erratic INR may reflect non-adherence to the medicine regimen, often due to misunderstandings of dosage requirements.

A missed dose of warfarin is usually reflected in the INR result warfarin and lipitor high inr value to five days after the missed dose, 12 although a response may be seen within 16 hours. In many cases, no explanation may be found for unstable INR values. It may be worthwhile discussing aspects of the dosing regimen. Changes in the INR may also be the result of occult causes, such as undisclosed drug use, lifestyle and medical causes.

Computerised decision support is a very useful tool for maintaining therapeutic INR levels in patients receiving anticoagulant treatment. There is evidence that computerised decision support can achieve improved therapeutic control in terms of INR, when compared with human performance, warfarin and lipitor high inr value. A best practice Decision Support module has warfarin and lipitor high inr value developed for managing warfarin treatment, based on data from the Coventry system, 17 which has been widely accepted internationally.

This module is available free to General Practices in New Zealand. It enables clinicians to more easily adjust oral anticoagulant doses and schedule follow-up consultations. INR results can be tracked and monitored over time and a dose calendar can be printed for the patient, warfarin and lipitor high inr value. A meta-analysis of warfarin and lipitor high inr value controlled trials compared computerised decision support methods of determining warfarin dosage with traditional manual methods in patients.

A randomised controlled trial compared the INR control by the percentage of time within-target of two groups of patients attending an anticoagulation clinic in Italy. One of the advantages of computerised decision support tools is that information can be easily retrieved, providing many opportunities for clinical practice audit, including identifying patients who are on anticoagulant treatment but are not receiving INR monitoring. Transfer of the care of a patient on warfarin treatment from secondary to primary care is associated with a high risk for several reasons:.

Some New Zealand hospitals have developed protocols for the timely transfer of information about warfarin therapy to primary care on patient discharge. Essential details have been found to be:. New Zealand hospitals use a variety of warfarin initiation protocols and there is little evidence that one is any better than another, warfarin and lipitor high inr value.

It is recommended to follow on with the diy plans design polarized circular antenna initiated in secondary care for patients who start warfarin in this environment. It would be helpful for primary care clinicians to become familiar with local hospital protocols.

Follow us on facebook, warfarin and lipitor high inr value. Login to my bpac. Use of INR for monitoring warfarin treatment Regular measurement of INR levels is an essential component in the management of patients receiving warfarin treatment. In this article INR monitoring is essential for all patients treated with warfarin Managing warfarin treatment Computerised decision support Guide for over anti-coagulation 18 Transfer of care across the primary secondary interface is associated with a high risk References In this article.

INR measurement is a key component in maintaining good control of warfarin treatment Practices should have clearly understood mechanisms in place to monitor patients treated with warfarin, to minimise the risks and maximise the benefits There is evidence that computerised decision support can achieve improved therapeutic control.

INR monitoring is essential for all patients treated with warfarin International Normalised Ratio INR testing is well established as an integral part of warfarin treatment. INR levels can be difficult to control Although regular testing of INR levels is essential for all people taking warfarin to maintain control of the INR, in practice, INR levels show considerable intra-patient variability.

Maintaining good systems is important It is important that practices develop a standardised management protocol for all patients treated with warfarin, in order to optimise health outcomes, by achieving tighter control. The method chosen will depend on how clinical records are managed within the practice but there should at least be a standard location within the patient notes for the following information: Managing alterations in the INR Some fluctuations in INR level can be expected, and for minor variations, changes in weekly doses are usually not required.

Diet or alcohol Patients on warfarin are usually advised to consume a reasonably consistent proportion of vitamin K rich foods such as broccoli, spinach and cabbage. Drug interactions Many medicines and herbal products can interact with warfarin. Increased bleeding warfarin and lipitor high inr value without alteration of INR. Interactions do not occur, warfarin and lipitor high inr value, or are not significant, in everyone. There warfarin and lipitor high inr value many variables including genetic factors.

This table does not include all possible interactions with warfarin. Please check before prescribing or recommending any medicine, herbal product or food supplement. Systemic or concurrent disease Warfarin and lipitor high inr value systemic diseases can influence INR results: Congestive heart failure may cause hepatic congestion of blood flow and inhibit warfarin metabolism, this may be particularly troublesome during exacerbations of heart failure.

Hypothyroidism decreased catabolism of vitamin K clotting factors may decrease INR values. Hyperthyroidism conversely, hyperthyroidism may increase catabolism of vitamin K clotting factors and increase INR values. Liver failure may cause elevation of INR due to reduced production of clotting factors. Other illnesses other intermittent conditions such as fever, vomiting and diarrhoea may affect the INR; ill patients may also reduce their usual dietary intake.

Non-adherence to dosage regimen An erratic INR may reflect non-adherence to the medicine regimen, often due to misunderstandings of dosage requirements. Unknown causes In many cases, no explanation may be found for unstable INR values. Computerised decision support Computerised decision support is a very useful tool for maintaining therapeutic INR levels in patients receiving anticoagulant treatment.

Major bleeding occurs If at any time major bleeding occurs: Stop warfarin Give vitamin K 10 mg, slow IV Refer to secondary care immediately for factor replacement. Transfer of care across the primary secondary interface is associated with a high risk Transfer of care across the primary secondary interface is associated with a high risk Transfer of the care of a patient on warfarin treatment from secondary to primary care is associated with a high risk for several reasons: Poor communication on discharge may leave the primary care clinician with inadequate information to make safe testing and dose adjustment decisions Patients sinus infection and doxycycline be discharged from hospital with tablet strengths, which were used for loading doses but are inappropriate for maintenance therapy.

Warfarin has a very long half-life, so accumulates, leading to over-anticoagulation Patients often leave hospital with other medicines, e. Essential details have been found to be: Anticoagulation in hospitals and general practice. Major hemorrhage and tolerability of warfarin in the first year of therapy among elderly patients with atrial fibrillation.

Primary Care Trust Anticoagulation Monitoring Service standard operating procedure for the provision of a Level 3, 4 and 5 anticoagulation service. NHS Sheffield; March Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians evidence-based clinical practice guidelines 8th Ed.

 

Warfarin and lipitor high inr value

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